Provider Demographics
NPI:1205219730
Name:POULSEN, MONICA (CADC-CAS)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:POULSEN
Suffix:
Gender:F
Credentials:CADC-CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HACKETT RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-9800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N 9TH ST STE A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5814
Practice Address - Country:US
Practice Address - Phone:209-558-4598
Practice Address - Fax:209-558-4586
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC033560415101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0400XMedicaid